Q: What is stress urinary incontinence?
A: Stress urinary incontinence is a common condition that affects approximately 25 percent of adult women. When a woman laughs, coughs, sneezes or exercises — anything that increases abdominal pressure — she may leak urine. Sometimes it’s a little spurt, sometimes it’s more than that. While it may be common, it’s certainly not “normal.”
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Urge Incontinence is the inability to control the flow of urine – it is usually due to uncontrolled “bladder spasms.” Women will say, “When I have to go, I have to go!” Women with this problem have bladders that do not allow them to fill with and store urine properly. Once the bladder fills with a certain amount of urine, it becomes irritable and “spasms”, resulting in leakage. This problem can be extremely embarrassing because a woman may soak through her undergarments or even the protection she is wearing.
Overflow Incontinence can be due to a poorly functioning bladder muscle or neurological problems. The bladder muscle does not “squeeze” or contract well enough so that it continues to fill up with urine until the urine finally “spills out”. This leakage can be provoked by straining or coughing.
Sometimes this problem occurs because of an “obstruction” of the normal flow of urine. This happens, for instance, when the bladder/uterus or vagina has “dropped” so much that it “kinks” the passageway (the urethra) from which the urine normally flows. Sometimes simply “re-supporting” these “dropped” pelvic organs treats this problem.
Mixed Incontinence is the combination of any of the above. This is important to know because treatment options may differ.
Lifestyles Changes
1) Stop smoking. Nicotine from cigarettes is a bladder irritant. When nicotine is present in the body, it acts directly on the muscle of the bladder causing it to have spasms (whether you are in the bathroom or not!) Women who smoke often also have a chronic cough. If you suffer from stress incontinence, coughing most certainly brings on more episodes of urinary loss. Women who smoke and cough often put additional pressure on the muscles and supports to the bladder, thus further weakening them.
2) Eliminate caffeine. Caffeine is also a bladder irritant. When caffeine is present in the body, it acts on the muscle of the bladder causing it to have spasms. Caffeine is also a diuretic, which means it causes your kidneys to excrete more urine; thus causing you to need to go to the bathroom more often. Note: Do not go “cold turkey” on your caffeine reduction as you may get caffeine withdrawal headaches. Instead, slowly wean down the amount you ingest. Be aware of products such Colas, other soft drinks, chocolate and tea – these all contain caffeine.
3) Go to the bathroom more frequently – This will reduce the amount of urine you are holding your bladder. Be aware of the time and try to empty your bladder every 3 hours or so (many women already do this). This is important especially in women who have “bladder spasms” because these bladders are unpredictable – as soon as they begin to get full of urine, they go into spasm, resulting in urine loss.
4) Go to the bathroom less frequently: Some women get into the habit of ‘never passing up a bathroom’. If you go to the bathroom ‘just because it’s there’, or ‘because I don’t want to take the chance that I’ll leak urine’, then what actually happens is that the bladder becomes trained NOT to hold as much urine as it is supposed to hold. If you go to the bathroom every hour or 2, then the bladder’s capacity becomes reduced. If the bladder is not given the chance to hold 12 ounces like it should, and you void when the bladder only has 7 ounces in it, then the bladder capacity becomes 7 ounces. Now you will feel urgency at only 7 ounces…..you’ll say, “I have to go”, so you’ll void before you have 7 ounces in. Then the bladder capacity becomes even lower. It becomes a vicious cycle. Try and void at every 3 hour intervals. Not sooner. Not later.
5) Exercise your pelvic floor muscle – daily! The pelvic floor muscle (the muscles that surround the bladder, vagina, rectum and uterus) are a very important part of a woman’s body. Unfortunately, women tend to ignore them. Our leg muscles are strengthened each time we walk, our arms muscles are used each time we bring a glass of water to our mouths, our neck and back muscles are used with us standing, walking, etc. Women cannot forget about their pelvic floor muscles. When these muscles are strengthened and toned, they can provide support and control to the pelvic floor.
How to Do Pelvic Floor Muscle Exercises
Technique
1. Begin while lying down, knees bent and legs parted. Place on hand over
Lower abdomen.
2. Tighten the muscles around the vagina and urethra as if you are trying to
prevent urine or gas (flatus) from leaking out.
3. With your abdominal hand, make sure you are not pushing or contracting
your abdominal muscles.
4. Breathe! Do not hold your breath. Do not push down, but rather “pull up” on
the vaginal muscles.
5. Think of the pelvic floor as an elevator. Contract muscles in stages, rising to
successive levels slowly. Always tighten to the second level before lifting,
coughing, sneezing, standing. This takes practice but can definitely help.
6. Contract pelvic floor muscles for 3-5 seconds with a 5-second rest period between each contraction. An example schedule would be sets of 10, four times a day, every day. You can do your pelvic floor muscles exercises anytime, anywhere: while driving, watching TV, reading, etc.
7. If you have an urge to void, rather than running to the bathroom, stop what
you are doing, squeeze/contract the pelvic muscles, hold 3-5 seconds, relax
and then squeeze again. The urge will subside and give you enough time
to get to the bathroom.
The Key to Success of Pelvic Floor Muscle Exercises
The Key to success of the Pelvic Floor Muscle (Kegel) exercises is that once you
can nicely isolate them, recruit them in the times of need! For example, if you anticipate a cough or sneeze coming on try and squeeze your pelvic floor muscle first. If you have an URGE to go to the bathroom, DO NOT RUN: rather, squeeze the pelvic floor muscles. Allow the urge to subside. Then walk to the bathroom. By squeezing the muscles, it will give you extra time to get to the bathroom. It is not easy but with practice it can certainly help reduce urine loss.
Non-Surgical Treatment Options
Pelvic Floor Rehabilitation Therapy
1. Biofeedback
Some women have trouble identifying and contracting their pelvic floor muscles. Some women squeeze their rear-end muscles or thighs, some women actually push down with their abdominal muscles. The pelvic muscles are the muscles one would squeeze if she were trying to stop urine or gas from coming out (but please, do not practice while you are emptying your bladder). Some women need to be taught how to perform these correctly.
Biofeedback is a program designed to help a woman correctly identify and isolate the proper pelvic muscles. Using, for instance, a vaginal probe and skin surface muscle electrodes (small sticky patches that are placed on the skin overlying the abdominal muscles and/or the buttock muscles) a woman may actually visualize on a computer screen the activity of the muscle she is contracting. She learns when she is exercising the proper muscle and when she is squeezing the wrong muscles.
2. Electrical Stimulation Therapy
Sometimes the pelvic floor muscles cannot adequately contract due to nerve damage (multiple vaginal births, delivering large babies, previous pelvic surgery). Electrical stimulation is similar to biofeedback with the exception that a gentle electric current is used that directly acts on the pelvic floor muscles, causing them to contract. This helps to “bypass” the activity of the damaged nerve.
The use of electrical stimulation has been shown to reduce episodes of urge incontinence. There are specific nerves that rest in the pelvic muscles that when stimulated, allow the bladder muscle to relax. This therapy helps prevent bladder spasms and has shown to be effective.
Medications
Medications can help with symptoms of both stress and urge incontinence. There are a number of medications that act to relax the bladder muscle and prevent spasms (examples: oxybutynin, Vesicare®, Detrol® ). They are relatively easy to take with few side effects, the most common one being dry mouth. These medications should not be taken if you have NARROW angle glaucoma; if you have OPEN angle glaucoma, it is safe to take these medications. If you are unsure what type of glaucoma you have, ask your ophthalmologist, and get his/her permission.
Other medications help to increase the muscle tone around the urethra (the tube that brings the urine from the bladder to the outside). Examples of these medications include: imipramine, pseudoephedrine (a common ingredient in sinus medication).
Local vaginal estrogen cream also improves the function of the urethra and reduces urinary urgency.
Vaginal Support Devices
Vaginal support devices can be used in attempt to “re-support” the bladder. A vaginal support device or “pessary” is a specially designed soft plastic device (similar to a contraceptive diaphragm) that supports the bladder, and the “bladder neck.” Use of this device prevents urine leakage during activity. Another option, is to wear a “super” tampon, which temporarily compresses the urethra, helping to prevent urine leakage.
Surgical Treatment Options
Before a woman has surgery for incontinence, an accurate diagnosis as to the cause of the incontinence should be made.
Your physician needs to know if the cause of your urinary incontinence is due to loss of support to the bladder and/or urethra, if the sphincter muscle in the urethra is functioning properly, and whether or not you have bladder spasms. Bladder testing (called “urodynamics”) helps determine the cause.
Surgical treatment is reserved for stress urinary incontinence. Urge incontinence (bladder spasms) is generally not treated surgically. If a woman has mixed incontinence (BOTH stress and urge incontinence), surgery will treat her stress incontinence but will not necessarily address her urge incontinence. Therefore, she must understand that she may need to continue taking medications in the future to treat her urge incontinence.
1. There is a very effective, minimally-invasive surgery available that has an approximately 85% success rate in treating STRESS urinary incontinence. Is is known as a ‘sling’ or ‘tape’ procedure. This is a same-day surgery and the procedure usually takes 30-45 minutes. A small incision is placed in the vagina, and a ‘mesh-tape’ is placed under the urethra and then attached to the pelvic floor muscles. Post-operative restrictions require no driving for approximately 5 days, and no heavy lifting for approximately 3-4 weeks.
2. Another minimally invasive option for STRESS incontinence is a urethral injection procedure. An example is a ‘collagen’ or ‘Durasphere®’ injection.
This is an office procedure done under local anesthesia. It does not take long (15-25 minutes) and women can resume her normal activities the next day. A pasty substance called “collagen” (similar to what is used in cosmetic surgery to bulk up the lips and reduce facial wrinkles) is injected into the part of the urethra where the weakened sphincter muscle is. It “bulks” up this area, and helps “close it”. (A very uncommon risk is that a woman is not able to empty her bladder, but this is only temporary). Since collagen is not permanent and does dissolve, women usually need this procedure done more than once. It is not ideal for young, active women since it is not long lasting.
3. For women who have significant bladder spasms, urinary URGENCY and URGE incontinence, there is a surgical option that may be appropriate for women when medications and life-style / behavioral changes fail to be effective. The procedure is called “InterStim® Sacral Neuromodulation Therapy.” We think of it as a ‘pacemaker’ for the bladder. A small wire is placed next to the nerves in the lower back (sacrum) that are responsible for bladder function. Through this wire, we can ‘quiet’ the nerves that feed the bladder. It is an outpatient procedure, but is very costly, so it is usually reserved from women who fail other therapies. It is not approved for women with known neurological conditions such as multiple sclerosis or Parkinson’s disease, and is less effective for women older than aged 75 years.